1
|
Ohman‐Hanson R, Alonso GT, Pyle L, McDonough R, Clements M. Management of diabetic ketoacidosis in children: Does early insulin glargine help improve outcomes? J Diabetes 2024; 16:e13597. [PMID: 39136541 PMCID: PMC11320748 DOI: 10.1111/1753-0407.13597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 05/15/2024] [Accepted: 06/11/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND Rebound hyperglycemia following the resolution of diabetic ketoacidosis (DKA) is common in pediatric patients with type 1 diabetes, increasing the risk of recurrent DKA and complicating the transition to subcutaneous insulin. Multiple studies suggest that early administration of long-acting insulin analogs during DKA management safely improves this transition. OBJECTIVE This study aimed to determine whether early insulin glargine administration in children with DKA prevents rebound hyperglycemia and recurrent ketosis without increasing the rate of hypoglycemia or hypokalemia. METHODS Patients aged <21 years presenting with DKA to Children's Mercy Kansas City between October 2012 and October 2016 were reviewed. They were categorized as Early (>4 h of overlap with intravenous [IV] insulin) and Late (<2 h of overlap) cohorts. RESULTS We reviewed 546 DKA admissions (365 Early and 181 Late). Rebound hyperglycemia (>180 mg/dL) was lower in the Early group (66% vs. 85%, p ≤ 0.0001). Hypoglycemia (<70 mg/dL) during IV insulin administration was higher in the Early group than in the Late group (27% vs. 19%, p = 0.042). Hypoglycemia within 12 h of IV insulin discontinuation was lower in the Early group (16% vs. 26%, p = 0.012). Recurrent ketosis, hypokalemia, and cerebral edema were not different between the groups. CONCLUSIONS Early glargine administration in pediatric DKA management is safe, decreases the rate of rebound hyperglycemia, and improves the transition to subcutaneous insulin. Hypoglycemia is less frequent following IV insulin discontinuation with early glargine, but the IV insulin rate may need to be reduced to minimize hypoglycemia during IV insulin infusion.
Collapse
Affiliation(s)
- Rebecca Ohman‐Hanson
- Pediatric EndocrinologyUniversity of Colorado School of Medicine, Anschutz Medical Campus and Children's Hospital ColoradoAuroraColoradoUSA
| | - G. Todd Alonso
- Pediatric EndocrinologyUniversity of Colorado School of Medicine, Anschutz Medical Campus and Children's Hospital ColoradoAuroraColoradoUSA
- Barbara Davis Center for Childhood DiabetesUniversity of Colorado, Anschutz Medical CampusAuroraColoradoUSA
| | - Laura Pyle
- Department of PediatricsUniversity of Colorado School of MedicineAuroraColoradoUSA
- Department of Biostatistics and InformaticsColorado School of Public HealthAuroraColoradoUSA
| | - Ryan McDonough
- Pediatric EndocrinologyChildren's Mercy HospitalKansas CityMissouriUSA
| | - Mark Clements
- Pediatric EndocrinologyChildren's Mercy HospitalKansas CityMissouriUSA
| |
Collapse
|
2
|
Ibarra F, Bae R, Haghighat B. Review of Subcutaneous Insulin Regimens in the Management of Diabetic Ketoacidosis in Adults and Pediatrics. Ann Pharmacother 2024:10600280241263357. [PMID: 39054791 DOI: 10.1177/10600280241263357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024] Open
Abstract
OBJECTIVE Summarize the studies evaluating the use of subcutaneous (SQ) insulin in the management of diabetic ketoacidosis (DKA) in adults and pediatrics. DATA SOURCES A PubMed literature search was conducted for articles published between 2000 and the end of May 2024 which contained the following terms in their title: (1) subcutaneous, glargine, or basal and (2) ketoa*. STUDY SELECTION AND DATA EXTRACTION Review articles, guidelines, meta-analysis, commentaries, studies not related to the acute management of DKA, studies evaluating continuous SQ insulin, animal studies, if the time to DKA resolution was not clearly defined, and studies where basal insulin was administered greater than 6 hours after the insulin infusion was started were excluded. DATA SYNTHESIS The electronic search identified 58 articles. Following the initial screening 38 articles were excluded and 3 were added after bibliography review. Of the 23 articles assessed for eligibility, 7 were excluded. Sixteen articles were included. Five studies compared SQ rapid/short-acting insulin and intravenous (IV) insulin infusions in adults, 4 compared SQ rapid/short-acting insulin and IV insulin infusions in pediatrics, 4 evaluated IV insulin infusions with or without SQ basal insulin in adults, and 3 evaluated IV insulin infusions with or without SQ basal insulin in pediatrics. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE In comparison with IV insulin infusions, rapid/short-acting SQ insulin regimens were associated with reduced ICU admission rates, hospital length of stay, and hospitalization costs. IV insulin infusion regimens that included a single SQ basal insulin dose upon therapy initiation were associated with reduced concurrent IV insulin infusion durations. CONCLUSION Studies reviewed suggest that SQ insulin regimens may be as effective and safe as IV insulin infusions in the management of DKA and are associated with the conservation of resources. Providers may refer to this review when establishing or modifying their DKA management protocols.
Collapse
Affiliation(s)
- Francisco Ibarra
- College of Osteopathic Medicine, California Health Sciences University, Clovis, CA, USA
- Department of Pharmacy Services, Community Regional Medical Center, Fresno, CA, USA
- Department of Emergency Medicine, University of California San Francisco at Fresno, Fresno, CA, USA
| | - Ryan Bae
- College of Osteopathic Medicine, California Health Sciences University, Clovis, CA, USA
| | - Bardya Haghighat
- College of Osteopathic Medicine, California Health Sciences University, Clovis, CA, USA
| |
Collapse
|
3
|
Alshurtan KS, Alnizari O, Aldarwish H, Al-Tufaif AA. Efficacy and Safety of Intravenous Insulin in Treatment of Patient With Diabetic Ketoacidosis: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e30721. [DOI: 10.7759/cureus.30721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2022] [Indexed: 11/07/2022] Open
|
4
|
Lim Y, Ohn JH, Jeong J, Ryu J, Kim SW, Cho JH, Park HS, Kim HW, Lee J, Kim ES, Kim NH, Jo YH, Jang HC. Effect of the Concomitant Use of Subcutaneous Basal Insulin and Intravenous Insulin Infusion in the Treatment of Severe Hyperglycemic Patients. Endocrinol Metab (Seoul) 2022; 37:444-454. [PMID: 35654578 PMCID: PMC9262694 DOI: 10.3803/enm.2021.1341] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 05/02/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGRUOUND No consensus exists regarding the early use of subcutaneous (SC) basal insulin facilitating the transition from continuous intravenous insulin infusion (CIII) to multiple SC insulin injections in patients with severe hyperglycemia other than diabetic ketoacidosis. This study evaluated the effect of early co-administration of SC basal insulin with CIII on glucose control in patients with severe hyperglycemia. METHODS Patients who received CIII for the management of severe hyperglycemia were divided into two groups: the early basal insulin group (n=86) if they received the first SC basal insulin 0.25 U/kg body weight within 24 hours of CIII initiation and ≥4 hours before discontinuation, and the delayed basal insulin group (n=79) if they were not classified as the early basal insulin group. Rebound hyperglycemia was defined as blood glucose level of >250 mg/dL in 24 hours following CIII discontinuation. Propensity score matching (PSM) methods were additionally employed for adjusting the confounding factors (n=108). RESULTS The rebound hyperglycemia incidence was significantly lower in the early basal insulin group than in the delayed basal insulin group (54.7% vs. 86.1%), despite using PSM methods (51.9%, 85.2%). The length of hospital stay was shorter in the early basal insulin group than in the delayed basal insulin group (8.5 days vs. 9.6 days, P=0.027). The hypoglycemia incidence did not differ between the groups. CONCLUSION Early co-administration of basal insulin with CIII prevents rebound hyperglycemia and shorten hospital stay without increasing the hypoglycemic events in patients with severe hyperglycemia.
Collapse
Affiliation(s)
- Yejee Lim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung Hun Ohn
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Joo Jeong
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jiwon Ryu
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sun-wook Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Ho Cho
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hee-Sun Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hye Won Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jongchan Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eun Sun Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Nak-Hyun Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hak Chul Jang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
- Corresponding author: Hak Chul Jang Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea Tel: +82-31-787-7005, Fax: +82-31-787-4290, E-mail:
| |
Collapse
|
5
|
Bass ME, Paavola N, Kiser TH, Wright G, Jacknin G. Evaluation of Insulin Infusion Rates for the Treatment of Diabetic Ketoacidosis in the Emergency Department. JOURNAL OF BIOSCIENCES AND MEDICINES 2022; 10:203-211. [PMID: 35386489 PMCID: PMC8983016 DOI: 10.4236/jbm.2022.103019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction: Objective: Methods: Results: Conclusion:
Collapse
Affiliation(s)
- Megan E. Bass
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - Nicole Paavola
- Department of Pharmacy, UCHealth, University of Colorado Hospital, Aurora, CO, USA
| | - Tyree H. Kiser
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - Garth Wright
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - Gabrielle Jacknin
- Department of Pharmacy, UCHealth, University of Colorado Hospital, Aurora, CO, USA
| |
Collapse
|
6
|
Mohamed A, Ploetz J, Hamarshi MS. Evaluation of Early Administration of Insulin Glargine in the Acute Management of Diabetic Ketoacidosis. Curr Diabetes Rev 2021; 17:e030221191986. [PMID: 33655870 DOI: 10.2174/1573399817666210303095633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/25/2021] [Accepted: 02/01/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Few studies have evaluated the early use of insulin glargine in the management of diabetic ketoacidosis (DKA) patients. Early insulin glargine use in DKA was safe and associated with a trend towards faster DKA resolution. OBJECTIVES To evaluate the efficacy and safety of early insulin glargine administration for acute management of DKA in critically ill patients. METHODS This single-center retrospective cohort study included patients, who were >18 years of age with DKA, admitted to the intensive care unit (ICU) for at least 12 h, and received intravenous insulin infusion for at least 6 h. The primary endpoint was the association between the time to insulin glargine administration and time to DKA resolution. Linear and logistic regression analyses were performed. RESULTS Of the 913 patients evaluated, 380 were included in the study. The overall mean age was 45±17 years, 196 (51.6%) were female, and 262 (70%) patients had type 1 diabetes mellitus. The mean blood glucose level was 584.9±210 mg/dL, pH was 7.16±0.17, anion gap was 28.17±6.9 mEq/L, and serum bicarbonate level was 11.19±5.72 mEq/L. Every 6-h delay in insulin glargine administration was associated with a 26-min increase in time to DKA resolution (95% confidence interval [CI], 14.76-37.44; p<0.0001), 3.2-h increase in insulin infusion duration (95% CI, 28.8-36; p<0.0001), and 6.5-h increase in ICU LOS (95% CI, 5.04-7.92; p<0.0001). CONCLUSION Early administration of insulin glargine is potentially safe and may be associated with a reduction in time to DKA resolution and a shorter duration of insulin infusion.
Collapse
Affiliation(s)
- Adham Mohamed
- Saint Luke's Hospital of Kansas City, 4401 Wornall Rd., Kansas City, MO 64111, United States
| | - Jeannette Ploetz
- Saint Luke's Hospital of Kansas City, 4401 Wornall Rd., Kansas City, MO 64111, United States
| | - Majdi S Hamarshi
- Saint Luke's Hospital of Kansas City, 4401 Wornall Rd., Kansas City, MO 64111, United States
| |
Collapse
|
7
|
Nader ND, Hamishehkar H, Naghizadeh A, Shadvar K, Iranpour A, Sanaie S, Chang F, Mahmoodpoor A. Effect of Adding Insulin Glargine on Glycemic Control in Critically Ill Patients Admitted to Intensive Care Units: A Prospective Randomized Controlled Study. Diabetes Metab Syndr Obes 2020; 13:671-678. [PMID: 32210600 PMCID: PMC7073596 DOI: 10.2147/dmso.s240645] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 02/20/2020] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE We aimed to examine the effects of adding a longer-acting insulin glargine to existing glucose control on reducing blood-glucose fluctuations in an intensive care unit (ICU). METHODS A total of 110 patients randomly received adjuvant insulin glargine 15 IU/day (glargine) or placebo (control), in addition to daily infusion of insulin to maintain glucose levels at a target of 140-180 mg/dL. End points were mean and variance of blood glucose and frequency of hypoglycemia, hyperglycemia, ICU stay, and mortality. Data were analyzed with repeated-measures ANOVA and Mann-Whitney U test. RESULTS Average daily glucose level was significantly less in the glargine group than controls (P<0.0001), while there was no difference in daily variance in blood glucose between the two groups. The duration of glucose concentrations being within the target range was identical between the glargine and control groups (16.6±4.9 vs 16.4±4.6 hours/day, P=0.844) during the 7 days of admission. The frequency of hypoglycemia was greater in the glargine group and total duration of hyperglycemia (>180 mg/dL) much longer among controls (P<0.001). Similar mortality rates were observed in both groups, while ICU length of stay was 2 days shorter in the glargine group. CONCLUSION Addition of insulin glargine to routine protocols more effectively reduces glucose levels and decreases incidence of hyperglycemic episodes and regular insulin usage. This adjustment may be associated with decreases in duration of ICU stay or increases in hypoglycemic events.
Collapse
Affiliation(s)
- Nader D Nader
- State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Hadi Hamishehkar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Abdolreza Naghizadeh
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kamran Shadvar
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Sarvin Sanaie
- Neurosiences Research Center, Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Francis Chang
- State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Ata Mahmoodpoor
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
- Correspondence: Ata Mahmoodpoor Anesthesiology, Tabriz University of Medical Sciences, School of Medicine, Tabriz, Iran Email
| |
Collapse
|
8
|
Rappaport SH, Endicott JA, Gilbert MP, Farkas JD, Clouser RD, McMillian WD. A Retrospective Study of Early vs Delayed Home Dose Basal Insulin in the Acute Management of Diabetic Ketoacidosis. J Endocr Soc 2019; 3:1079-1086. [PMID: 31069278 PMCID: PMC6500796 DOI: 10.1210/js.2018-00400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 04/05/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Insulin via continuous intravenous infusion (ICII) is a standard of care for treating patients with diabetic ketoacidosis (DKA). Once DKA is resolved, ICII is transitioned to subcutaneous therapy. However, recent guidelines recommend continuation of home dose subcutaneous basal insulin (HDBI) in patients with DKA. The objective of this study was to evaluate outcomes in patients who received early vs delayed HDBI. METHODS This is a retrospective cohort study of patients ≥16 years old admitted to the medical intensive care unit between 1 July 2012 and 30 June 2015 with a primary diagnosis of DKA who received ICII and HDBI. Patients were stratified into early or delayed groups if they received HDBI before or after resolution of DKA, respectively. The primary outcome was incidence of transitional failure, defined as resumption of ICII or recurrence of DKA after initial ICII discontinuation. RESULTS A total of 106 admissions were included for analysis; 33 (31.1%) received early HDBI. The incidence of transitional failure was similar between the early and delayed groups (OR, 0.60; 95% CI, 0.26 to 1.44; P = 0.72). In the early group, ICII duration was shorter at 13.8 hours [interquartile range (IQR), 10.1 to 16.5] vs 17.1 hours (IQR, 12.6 to 21.1; P = 0.04), with a trend toward lower rates of hypoglycemia (OR, 0.41; 95% CI, 0.16 to 1.05; P = 0.058). CONCLUSION There was no significant difference in incidence of transitional failure between early and delayed HDBI. Early HDBI was associated with a shorter duration of ICII and a trend toward less hypoglycemia. A prospective analysis is needed to confirm these findings.
Collapse
Affiliation(s)
- Stephen H Rappaport
- Department of Pharmacy, The University of Rochester Medical Center, Rochester, New York
| | - Jeffrey A Endicott
- Department of Pharmacy, The University of Vermont Medical Center, Burlington, Vermont
| | - Matthew P Gilbert
- Department of Medicine, Division of Endocrinology and Diabetes, Larner College of Medicine at The University of Vermont, Burlington, Vermont
| | - Joshua D Farkas
- Department of Medicine, Division of Pulmonary Disease and Critical Care Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont
| | - Ryan D Clouser
- Department of Medicine, Division of Pulmonary Disease and Critical Care Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont
| | - Wesley D McMillian
- Department of Pharmacy, The University of Vermont Medical Center, Burlington, Vermont
- Department of Surgery, Division of Acute Care Surgery, The University of Vermont Medical Center, Burlington Vermont
| |
Collapse
|
9
|
Usman A, Makmor Bakry M, Mustafa N, Rehman IU, Bukhsh A, Lee SWH, Khan TM. Correlation of acidosis-adjusted potassium level and cardiovascular outcomes in diabetic ketoacidosis: a systematic review. Diabetes Metab Syndr Obes 2019; 12:1323-1338. [PMID: 31496770 PMCID: PMC6689561 DOI: 10.2147/dmso.s208492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/05/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND During the progress and resolution of a diabetic ketoacidosis (DKA) episode, potassium levels are significantly affected by the extent of acidosis. However, none of the current guidelines take into account acidosis during resuscitation of potassium level in DKA management, which may increase the risk of cardiovascular adverse events. OBJECTIVE To assess literature regarding the adjustment of potassium level using pH to calculate pH-adjusted corrected potassium level, and to observe the relationship of cardiovascular outcomes with reported potassium level and pH-adjusted corrected potassium in DKA. METHODOLOGY Seven databases were searched from inception to January 2018 for studies which had reported people with diabetes developing diabetic ketoacidosis, in relation to prevalence or incidence, fluid resuscitation or potassium supplementation treatment, treatment or cardiovascular outcomes, and experimentation with DKA management or insulin. Quality of studies was evaluated using Cochrane Risk of Bias and Newcastle Ottawa Scale. RESULTS Forty-seven studies were included in qualitative synthesis out of a total of 10,292 retrieved studies. Forty-one studies discussed the potassium level and blood pH at the time of admission, ten studies discussed cardiovascular outcomes, and only four studies concurrently discussed potassium level, pH, and cardiovascular outcomes. Only two studies were graded as good on the Newcastle Ottawa Scale. The reported potassium level was well within normal range (5.8 mmol/L), whereas pH rendered patients to be moderately acidotic (7.13). Surprisingly, none of the included studies mentioned pH-adjusted corrected potassium level and, hence, this was calculated later. Although mean corrected potassium was within the normal range (3.56 mmol/L), 13 studies had corrected potassium below 3.5 mmol/L and five had it below 3.0 mmol/L. Nevertheless, with the exception of one study, none discussed cardiovascular outcomes in the context of potassium or pH-adjusted potassium level. CONCLUSION The evidence surrounding cardiovascular outcomes during DKA episodes in light of a pH-adjusted corrected potassium level is scarce. A prospective observational, or preferably, an experimental study in this regard will ensure we can modify and enhance safety of existing DKA treatment protocols.
Collapse
Affiliation(s)
- Atif Usman
- School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia
- Correspondence: Atif UsmanSchool of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan47500, Bandar Sunway, Selangor, MalaysiaEmail
| | - Mohd Makmor Bakry
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Norlaila Mustafa
- Department of Endocrinology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Inayat Ur Rehman
- School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia
- Department of Pharmacy, Abdul Wali Khan University, Mardan, Pakistan
| | - Allah Bukhsh
- School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Shaun Wen Huey Lee
- School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia
| | - Tahir Mehmood Khan
- School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
- Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes, Health and Well-being Cluster, Global Asia in the 21st Century Platform, Monash University Malaysia, Selangor, Malaysia
- Tahir Mehmood KhanSchool of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan47500, Bandar Sunway, Selangor, MalaysiaEmail ;
| |
Collapse
|
10
|
Harrison VS, Rustico S, Palladino AA, Ferrara C, Hawkes CP. Glargine co-administration with intravenous insulin in pediatric diabetic ketoacidosis is safe and facilitates transition to a subcutaneous regimen. Pediatr Diabetes 2017; 18:742-748. [PMID: 27807910 PMCID: PMC5415439 DOI: 10.1111/pedi.12462] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 09/16/2016] [Accepted: 09/22/2016] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Diabetes ketoacidosis (DKA) is a common presentation and complication of type 1 diabetes (T1D). While intravenous insulin is typically used to treat acute metabolic abnormalities, the transition from intravenous to subcutaneous treatment can present a challenge. We hypothesize that co-administration of glargine, a subcutaneous long-acting insulin analog, during insulin infusion may facilitate a flexible and safe transition from intravenous to subcutaneous therapy. OBJECTIVE To determine if the practice of administering subcutaneous glargine during intravenous insulin is associated with an increased risk of hypoglycemia, hypokalemia, or other complications in children with DKA. METHODS Retrospective chart review of patients aged 2 to 21 years, presenting to our center with DKA between April 2012 and June 2014. Patients were divided into two groups: those co-administered subcutaneous glargine with intravenous insulin for over 4 hours (G+); and patients with less than 2 hours of overlap (G-). RESULTS We reviewed 149 DKA admissions (55 G+, 94 G-) from 129 unique patients. There was a similar incidence of hypoglycemia between groups (25% G+ vs 20% G-, P = 0.46). Hypokalemia (<3.5 mmol/L) occurred more frequently in the G+ group (OR = 3.4, 95% CI 1.7-7.0, P = 0.001). Cerebral edema occurred in 2/55 (3.6%) of the G- group and none of the G+ subjects. CONCLUSION Co-administration of glargine early in the course of DKA treatment is well tolerated and convenient for discharge planning; however, this approach is associated with an increased risk of hypokalemia.
Collapse
Affiliation(s)
- V Sanoe Harrison
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Stacy Rustico
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Andrew A Palladino
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Christine Ferrara
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Colin Patrick Hawkes
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, USA,The National Children's Research Centre, Dublin, Ireland
| |
Collapse
|